PROJECT SUMMARY The burden of adolescent unintended pregnancy in the US is substantial, despite declines in pregnancy rates in recent years. Although highly effective contraceptive methods exist, adolescents face multi-level barriers to contraceptive access and use. Research focused on increasing contraception initiation among adolescents is crucial. The emergency department (ED) is a non-traditional setting that is well-positioned to provide reproductive care, as almost 19 million adolescents seek care in EDs each year, many are amenable to receiving care in this setting, and the ED is often the only or primary contact with the health care system for the highest-risk youth. We propose a novel contraceptive counseling intervention for the ED setting that address barriers at the patient, provider, and system levels. Building on previous work and drawing on proven strategies from traditional settings, we will train ED advanced practice nurses to provide counseling utilizing Motivational Interviewing strategies to facilitate uptake of ED-based contraception or clinic referral among sexually active females aged 15-18 years. We will conduct a small randomized trial to evaluate these feasibility constructs using mixed methodology: acceptability, demand, implementation, practicality, adaptation, integration, expansion, and limited-efficacy. We compare two arms (intervention vs. enhanced standard of care) to determine size of effect rates on contraception initiation. We gather data to inform a future study to evaluate individual components and identify the most parsimonious combination of active components using an adaptive design. We expect these data to inform a trial with adequate sample to evaluate efficacy among contraceptive subtypes and to identify characteristics that enhance or inhibit contraception use. This project is significant because the national burden of adolescent childbearing ($9.4 billion for one year alone) is so great, even a small reduction in incidence should lead to significant cost reductions and reduce generational cycles of poverty and poor health outcomes.